Fitness-to-work examinations are objective assessments of the health of employees in relation to their specific jobs, in order to ensure they could do the job and would not be a hazard to themselves or others. Fitness-to-work examinations should always be conducted with reference to the specific job the worker holds or intends to hold. The circumstances that require such examinations occur at the time of application or consideration for entry into employment and assignment to a specific job (pre-placement), return to work after illness or injury (return to work).
To be useful to the employee and employer and to be consistent with human-rights legislation, pre-placement examinations must be structured so that they are specific to the working conditions and job requirements medically and are timed after a job offer has been made. An employer cannot arbitrarily deny a person a job opportunity on the basis of a physical or emotional disability. However, the job offer can be made contingent upon passing a medical examination that indicates the employee would be able to perform the job and would not be a hazard to him or herself or others while working in that job. The employee may be refused the job only if the health of the employee is not compatible with the working conditions, and the job requirements cannot reasonably be altered.
There are six possible judgments, the appropriateness of which may depend on the type of fitness-to-work examination being done: fit, temporarily fit, fit subject to work modifications, temporarily fit subject to work modifications, temporarily unfit, and permanently unfit. These categories are defined below:
- Fit: This judgment means that the employee is able to perform the job without danger to self or others, without reservation. The subcategory "temporarily" can be used for all types of medical assessments except pre-placement. "Permanently" should never be used with a judgment of "fit" since physicians cannot see into the future.
- Fit subject to work modifications: A judgment in this category indicates that the employee could be a hazard to self or others if employed in the job as described but would be considered fit to do the job if certain working conditions were modified (e.g., changing the way the work is performed or the working environment). The modifications required must be clearly described in the comments section. If these can be accommodated, the employee is considered fit for the modified job. If the modifications cannot be reasonably accommodated, the employee is deemed temporarily or permanently unfit. "Temporarily" means that if the person's condition improves with time, the requirement for work modifications may be lifted. "Permanently" means that the employee will never be fit for the job without the modifications. Any employee considered fit subject to work modifications must be fully informed of both the medical findings and the modifications.
- Unfit: This category describes the employee who is unable to perform the job without being a hazard to self or others. This judgment and the subcategories "temporarily" and "permanently" can be used with any type of fitness-to-work examination. "Temporarily" means that the medical condition may improve with time, thus allowing return to work or transfer to some other job. "Permanently" usually means that the employee will never be fit for the job and that no modification of the working conditions is reasonably possible or medically relevant; if "permanently" means that the employee is unable to do any available job, with or without work modifications, a statement to this effect should be made in the comments section.
Key Elements of a Fitness-for-Duty Examination Under the Americans with Disabilities Act
- Determine the presence or absence of a permanent impairment that substantially limits one or more major life activities.
- Evaluate the patient's work capacity (mental and physical) and delineate workplace restrictions.
- Assess workplace demands (mental and physical) and essential functions of the job.
- Ascertain the patient's ability to perform the essential functions of the job with, or without, accommodations.
Practical Pointers on Disability Evaluations and Certifications
- Do not confuse the terms "impairment" and "disability." Impairment can be defined as a loss of physiologic function or anatomic structure. By contrast, disability can be defined as a reduced ability to meet occupational demands as a result of impairment and other associated factors. Therefore, disability is a broad term that encompasses not only impairment but also a multitude of other factors.
- Obtain appropriate consents signed and dated by the patient.
- Clearly delineate the nature and extent of all impairments (mental and physical); segregate those pertaining to the claim.
- Document all patient limitations (mental and physical) and workplace restrictions.
- Assess the patient's workplace demands (mental and physical) and essential functions of the job by obtaining a functional job analysis from the employer.
- Assess fitness for duty and employability by comparing the patient's work capacity to workplace demands. Obtain a functional capacity examination if needed. (See Procedure Summary in the original guideline document.)
- Ascertain the type and definition of disability being applied to the claim.
- Determine disability status and address issues of temporary versus permanent, as well as partial versus total disability.
- List patient's capabilities, limitations, and restrictions.
- Do not address issues of permanency (including impairment or disability) until the patient has reached maximum medical improvement.
- Complete disability certification forms objectively, accurately and in a timely manner.
- Beware of hidden patient agendas and secondary gain from disability.
When considering whether a worker is fit for duty, an appreciation for the workplace in general and the specific task(s) is crucial. The physician needs a detailed job description from the employer. Ideally, this information should be corroborated by the worker. The physician's role includes: (1) providing a critical assessment of the available medical information as to completeness and validity, (2) identifying impairments that can "reasonably be anticipated" to affect performance of essential functions, (3) determining if impairments are permanent, and (4) identifying impairments that may result in a sudden or gradual adverse consequence (e.g., incapacitation in a safety-sensitive job, communicable disease) or a "direct threat" (i.e., significant risk of substantial harm to the health or safety of self, co-workers, or the public that cannot be eliminated by reasonable accommodation).
